Medicine and Health Sciences Commons^™

The Role Of Correctional Officers In Multidisciplinary Mental Health Care In Prisons, Kenneth Appelbaum, James Hickey, Ira Packer

Ira K Packer

Prisons have become the homes of thousands of inmates who have mental disorders. The stress of incarceration can cause morbidity among these individuals, resulting in more severe symptoms and more disruptive behavior. Effective treatment for such inmates often involves services provided by a multidisciplinary treatment team that includes correctional officers. Correctional officers can assist in observations and interventions, and they play a unique role on specialized housing units. Successful collaboration between correctional officers and treatment teams requires a foundation of mutual respect, shared training, and ongoing communication and cooperation. With these elements in place, correctional officers can assist the treatment …

Pulling Together And Pushing Apart: Tides Of Tension In The Icu Team, Laura Hawryluck, Sherry Espin, Kim Garwood, Cathy Evans, Lorelei Lingard

Lorelei Lingard

No abstract provided.

Working Off The Record: Physicians' And Nurses' Transformations Of Electronic Patient Record-Based Patient Information, Lara Varpio, Catherine Schryer, Pascale Lehoux, Lorelei Lingard

Lorelei Lingard

BACKGROUND: Electronic patient records (EPRs) are increasingly being used in health care, but little is known about how EPR-based patient information is used in daily care activities, nor about its potential influence on novice training.

METHOD: Seventy-two physicians and nurses participated in an eight-month study on a single pediatric ward. Eighty hours of nonparticipant observations and 20 interviews were conducted. Data were analyzed using constructivist grounded theory and visual rhetoric.

RESULTS: Three main features of participant interactions with EPR-based information were identified: (1) EPR-based information was routinely transformed into paper documents; (2) these transformations were organized by profession-specific guiding principles; …

Tensions Influencing Operating Room Team Function: Does Institutional Context Make A Difference?, Lorelei Lingard, Stacey Garwood, Dan Poenaru

Lorelei Lingard

BACKGROUND: A recent study of operating room (OR) team communication in a large, urban hospital described recurrent tension catalysts and a preliminary theory of team members' interpretive processes. To determine to what extent these findings were transferable to other institutional contexts, we conducted a validation study in 2 small, academic hospitals in a mid-size city. METHODS: Eight focus groups and 8 interviews were conducted with 6 general surgeons, 22 OR nurses, 5 anaesthesiologists and 10 trainees. Observations of 10 surgeons and their team members were conducted over 4 months. Data were analysed by applying thematic codes derived from previous research …

A Qualitative Study Examining Tensions In Interdoctor Telephone Consultations, Anupma Wadhwa, Lorelei Lingard

Lorelei Lingard

OBJECTIVE: Communication skills have gained increasing attention in medical education. Much of the existing literature and medical curricula addresses issues of doctor-patient communication. The critical importance of communication between health professionals, however, is now coming under the spotlight. The interdoctor telephone consultation is a common health care setting in which health professional communication skills are exercised. Breakdowns in this communication commonly occur and, surprisingly, this skill is not formally addressed in medical training. This study sought to clarify the communication issues that can occur during interdoctor telephone consultations in order to inform future educational initiatives in this domain. METHODS: Data …

Forming Professional Identities On The Health Care Team: Discursive Constructions Of The 'Other' In The Operating Room, Lorelei Lingard, R. Reznick, I. Devito, S. Espin

Lorelei Lingard

BACKGROUND: Inter-professional health care teams represent the nucleus of both patient care and the clinical education of novices. Both activities depend upon the'talk' that team members use to interact with one another. This study explored team members' interpretations of tense team communications in the operating room (OR). METHODS: The study was conducted using 52 team members divided into 14 focus groups. Team members comprised 13 surgeons, 19 nurses, nine anaesthetists and 11 trainees. Both uni-disciplinary (n = 11) and multi-disciplinary (n = 3) formats were employed. All groups discussed three communication scenarios, derived from prior ethnographic research. Discussions were audio-recorded …

A Qualitative Study Of Interphysician Telephone Consultations: Extending The Opinion Leader Theory, Anupma Wadhwa, Elizabeth Ford-Jones, Lorelei Lingard

Lorelei Lingard

INTRODUCTION: It has been suggested that the use of opinion leaders in the dissemination of information may be an effective method of changing clinical practice. Recent reviews on this topic, however, have found mixed results and have concluded that further research is needed to explore the circumstances that effectively utilize opinion leaders. We studied the interphysician telephone consultation, a situation in medical practice in which we see opinion leaders at work, to generate a grounded theory of opinion leader activity. METHODS: Data were collected and triangulated among 3 sources: documentation of 129 telephone consultations received, 51 hours of field observations …

Team Communications In The Operating Room: Talk Patterns, Sites Of Tension, And Implications For Novices, Lorelei Lingard, Richard Reznick, Sherry Espin, Glenn Regehr, Isabella Devito

Lorelei Lingard

PURPOSE: Although the communication that occurs within health care teams is important to both team function and the socialization of novices, the nature of team communication and its educational influence are not well documented. This study explored the nature of communications among operating room (OR) team members from surgery, nursing, and anesthesia to identify common communicative patterns, sites of tension, and their impact on novices.

METHOD: Paired researchers observed 128 hours of OR interactions during 35 procedures from four surgical divisions at one teaching hospital. Brief, unstructured interviews were conducted following each observation. Field notes were independently read by each …

Communication Failures In The Operating Room: An Observational Classification Of Recurrent Types And Effects, Lorelei Lingard, S. Espin, S. Whyte, G. Regehr, G. Baker, R. Reznick, J. Bohnen, B. Orser, D. Doran, E. Grober

Lorelei Lingard

BACKGROUND: Ineffective team communication is frequently at the root of medical error. The objective of this study was to describe the characteristics of communication failures in the operating room (OR) and to classify their effects. This study was part of a larger project to develop a team checklist to improve communication in the OR. METHODS: Trained observers recorded 90 hours of observation during 48 surgical procedures. Ninety four team members participated from anesthesia (16 staff, 6 fellows, 3 residents), surgery (14 staff, 8 fellows, 13 residents, 3 clerks), and nursing (31 staff). Field notes recording procedurally relevant communication events were …

Towards Safer Interprofessional Communication: Constructing A Model Of "Utility" From Preoperative Team Briefings, Lorelei Lingard, Sarah Whyte, Sherry Espin, G. Baker, Beverley Orser, Diane Doran

Lorelei Lingard

"Improved team communication" is broadly advocated in the discourse on safety but rarely supported by a precise understanding of the relationship between specific communication practices and concrete improvements in collaborative work processes. We sought to improve such understanding by analyzing the discourse arising from structured preoperative team briefings among surgeons, nurses, and anesthesiologists prior to general surgery procedures. Analysis of observers' fieldnotes from 302 briefings yielded a two-part model of communicative "utility", defined as the visible impact of communication on team awareness and behavior. "Informational utility" occurred when team awareness or knowledge was improved by provision of new information, explicit …

The Rules Of The Game: Interprofessional Collaboration On The Intensive Care Unit Team, Lorelei Lingard, Sherry Espin, Cathy Evans, Laura Hawryluck

Lorelei Lingard

BACKGROUND: The intensive care unit (ICU) is a nexus for interspecialty and interdisciplinary tensions because of its pivotal role in the care of the hospital's most critically ill patients and in the management of critical care resources. In an environment charged with temporal, financial and professional tensions, learning how to get results collaboratively is a critical aspect of professional competence. This study explored how team members in the ICU interact to achieve daily clinical goals, delineate professional boundaries and negotiate complex systems issues. METHODS: Seven 1-hour focus groups were conducted with ICU team members in two hospitals. Participants consisted of …

Learning Oral Presentation Skills A Rhetorical Analysis With Pedagogical And Professional Implications, Richard Haber, Lorelei Lingard

Lorelei Lingard

OBJECTIVE: Oral presentation skills are central to physician-physician communication; however, little is known about how these skills are learned. Rhetoric is a social science which studies communication in terms of context and explores the action of language on knowledge, attitudes, and values. It has not previously been applied to medical discourse. We used rhetorical principles to qualitatively study how students learn oral presentation skills and what professional values are communicated in this process. DESIGN: Descriptive study. SETTING: Inpatient general medicine service in a university-affiliated public hospital. PARTICIPANTS: Twelve third-year medical students during their internal medicine clerkship and 14 teachers. MEASUREMENTS: …

Time As A Catalyst For Tension In Nurse-Surgeon Communication, Sherry Espin, Lorelei Lingard

Lorelei Lingard

Carefully studying communication patterns between nurses and surgeons questions popular stereotypes about OR discourse and expands educators' understanding of the factors that motivate team communication, patterns that are habitual among team members, and issues that act as catalysts for tension. This study examines the nature of communication between perioperative nurses and surgeons and identifies patterns and sites of tension. Researchers observed 128 hours of interaction between nurses and surgeons in four surgical divisions at one teaching hospital in Ontario, Canada. Field notes were read, coded, and analyzed independently. Results showed that higher tension in nurse-surgeon communication clusters around particular themes, …

Surgeons Managing Conflict: A Framework For Understanding The Challenge, David Rogers, Lorelei Lingard

Lorelei Lingard

No abstract provided.

Perceptions Of Operating Room Tension Across Professions: Building Generalizable Evidence And Educational Resources, Lorelei Lingard, Glenn Regehr, Sherry Espin, Isabella Devito, Sarah Whyte, Douglas Buller, Bohdan Sadovy, David Rogers, Richard Reznick

Lorelei Lingard

BACKGROUND: Effective team communication is critical in health care, yet no curriculum exists to teach it. Naturalistic research has revealed systematic patterns of tension and profession-specific interpretation of operating room team communication. Replication of these naturalistic findings in a controlled, video-based format could provide a basis for formal curricula. METHOD: Seventy-two surgeons, nurses, and anesthesiologists independently rated three video-based scenarios for the three professions' level of tension, responsibility for creating tension and responsibility for resolution. Data were analyzed using three-way, mixed-design analyses of variance. RESULTS: The three professions rated tension levels of the various scenarios similarly (F=1.19, ns), but rated …

Getting Teams To Talk: Development And Pilot Implementation Of A Checklist To Promote Interprofessional Communication In The Or, Lorelei Lingard, S. Espin, B. Rubin, S. Whyte, M. Colmenares, G. Baker, D. Doran, E. Grober, B. Orser, J. Bohnen, R. Reznick

Lorelei Lingard

BACKGROUND: Pilot studies of complex interventions such as a team checklist are an essential precursor to evaluating how these interventions affect quality and safety of care. We conducted a pilot implementation of a preoperative team communication checklist. The objectives of the study were to assess the feasibility of the checklist (that is, team members' willingness and ability to incorporate it into their work processes); to describe how the checklist tool was used by operating room (OR) teams; and to describe perceived functions of the checklist discussions.

METHODS: A checklist prototype was developed and OR team members were asked to implement …

Basing The Evaluation Of Professionalism On Observable Behaviors: A Cautionary Tale, Shiphra Ginsburg, Glenn Regehr, Lorelei Lingard

Lorelei Lingard

PROBLEM STATEMENT AND BACKGROUND: The evaluation of professionalism often relies on the observation and interpretation of students' behaviors; however, little research is available regarding faculty's interpretations of these behaviors.

METHOD: Interviews were conducted with 30 faculty, who were asked to respond to five videotaped scenarios in which students are placed in professionally challenging situations. Behaviors were catalogued by person and by scenario.

RESULTS: There was little agreement between faculty about what students should and should not do in each scenario. Abstracted principles (e.g., honesty, altruism) were defined and applied inconsistently, both between and within individual faculty. There was no apparent …

The Rhetorical 'Turn' In Medical Education: What Have We Learned And Where Are We Going?, Lorelei Lingard

Lorelei Lingard

This paper presents a critical reflection on the contributions and challenges associated with one rhetorical approach to studying teaching and learning communication in health professions education. A rhetorical approach treats language as a social act, and attends to the role of language in establishing professional identities and relationships. The research has produced insights into the use of standard communication formats to teach novices, the nature of socialization on clinical teams, and the relationship between communication patterns and patient safety. Challenges and emerging questions include the problem of accounting for the material dimensions of communication in a rhetorical model, grappling with …

Persistence Of Unsafe Practice In Everyday Work: An Exploration Of Organizational And Psychological Factors Constraining Safety In The Operating Room, S. Espin, Lorelei Lingard, G. Baker, G. Regehr

Lorelei Lingard

This paper explores the factors that influence the persistence of unsafe practice in an interprofessional team setting in health care, towards the development of a descriptive theoretical model for analyzing problematic practice routines. Using data collected during a mixed method interview study of 28 members of an operating room team, participants' approaches to unsafe practice were analyzed using the following three theoretical models from organizational and cognitive psychology: Reason's theory of "vulnerable system syndrome", Tucker and Edmondson's concept of first and second order problem solving, and Amalberti's model of practice migration. These three theoretical approaches provide a critical insight into …

Routine And Adaptive Expert Strategies For Resolving Ict Mediated Communication Problems In The Team Setting, Lara Varpio, Catherine F Schryer, Lorelei Lingard

Lorelei Lingard

CONTEXT: The use of information and communication technologies (ICTs) for supporting interprofessional communication is becoming increasingly common in health care. However, little research has explored how ICTs affect interprofessional communication, or how novices are trained to be effective interprofessional ICT users. This study explores the interprofessional communication strategies of nurses and doctors (trainees and experts) when their communications were mediated by a specific ICT: an electronic patient record (EPR).

METHODS: A total of 72 doctors and nurses participated in this 8-month study on a paediatric in-patient ward. Eighty hours of non-participant observations and 20 semi-structured interviews were conducted. All data …

What's So Great About Rehabilitation Teams? An Ethnographic Study Of Interprofessional Collaboration In A Rehabilitation Unit, Lynne Sinclair, Lorelei Lingard, Ravindra Mohabeer

Lorelei Lingard

OBJECTIVE: To explore team structures, team relationships, and organizational culture constituting interprofessional collaboration (IPC) in a particular rehabilitation setting; to develop a description of IPC practice that may be translated, adapted, and operationalized in other clinical environments.

DESIGN: An ethnographic study involving: Field observations: 40 hours, over 4 weeks, daily activities, 7 interprofessional meetings, 3 care planning meetings, 1 business meeting, and 3 family meetings; Individual observations: a physiotherapist, an occupational therapist, and a social worker individually observed for 45 minutes to an hour; and Interviews: 19 participants, 11 professions, 27 informal, 5 formal interviews. Data analysis consisted of an …

Communication Channels In General Internal Medicine: A Description Of Baseline Patterns For Improved Interprofessional Collaboration, Lesley Gotlib Conn, Lorelei Lingard, Scott Reeves, Karen-Lee Miller, Ann Russell, Merrick Zwarenstein

Lorelei Lingard

General internal medicine (GIM) is a communicatively complex specialty because of its diverse patient population and the number and diversity of health care providers working on a medicine ward. Effective interprofessional communication in such information-intensive environments is critical to achieving optimal patient care. Few empirical studies have explored the ways in which health professionals exchange patient information and the implications of their chosen communication forms. In this article, we report on an ethnographic study of health professionals' communication in two GIM wards through the lens of communication genre theory. We categorize and explore communication in GIM into two genre sets-synchronous …

Preserving Professional Credibility: Grounded Theory Study Of Medical Trainees' Requests For Clinical Support, Tara Kennedy, Glenn Regehr, G. Baker, Lorelei Lingard

Lorelei Lingard

OBJECTIVE: To develop a conceptual framework of the influences on medical trainees' decisions regarding requests for clinical support from a supervisor.

DESIGN: Phase 1: members of teaching teams in internal and emergency medicine were observed during regular clinical activities (216 hours) and subsequently completed brief interviews. Phase 2: 36 in depth interviews were conducted using videotaped vignettes to probe tacit influences on decisions to request support. Data collection and analysis used grounded theory methods.

SETTING: Three teaching hospitals in an urban setting in Canada.

PARTICIPANTS: 124 members of teaching teams on general internal medicine wards and in the emergency department, …

Rules Of Engagement: Residents' Perceptions Of The In-Training Evaluation Process, Christopher Watling, Cynthia Kenyon, Elaine Zibrowski, Valerie Schulz, Mark Goldszmidt, Indu Singh, Heather Maddocks, Lorelei Lingard

Lorelei Lingard

BACKGROUND: In-training evaluation reports (ITERs) often fall short of their goals of promoting resident learning and development. Efforts to address this problem through faculty development and assessment-instrument modification have been disappointing. The authors explored residents' experiences and perceptions of the ITER process to gain insight into why the process succeeds or fails.

METHOD: Using a grounded theory approach, semistructured interviews were conducted with 20 residents. Constant comparative analysis for emergent themes was conducted.

RESULTS: All residents identified aspects of "engagement" in the ITER process as the dominant influence on the success of ITERs. Both external (evaluator-driven, such as evaluator credibility) …

Interprofessional Communication And Medical Error: A Reframing Of Research Questions And Approaches, Lara Varpio, Pippa Hall, Lorelei Lingard, Catherine Schryer

Lorelei Lingard

Progress toward understanding the links between interprofessional communication and issues of medical error has been slow. Recent research proposes that this delay may result from overlooking the complexities involved in interprofessional care. Medical education initiatives in this domain tend to simplify the complexities of team membership fluidity, rotation, and use of communication tools. A new theoretically informed research approach is required to take into account these complexities. To generate such an approach, we review two theories from the social sciences: Activity Theory and Knotworking. Using these perspectives, we propose that research into interprofessional communication and medical error can develop better …

Biomedical Scientists' Perception Of The Social Sciences In Health Research, Mathieu Albert, Suzanne Laberge, Brian Hodges, Glenn Regehr, Lorelei Lingard

Lorelei Lingard

The growing interest in interdisciplinary research within the Canadian health sciences sector has been manifested by initiatives aimed at increasing the involvement of the social sciences in this sector. Drawing on Bourdieu's concept of field and Knorr-Cetina's concept of epistemic culture, this study explores the extent to which it is possible for the social sciences to integrate into, and thrive in, a field in which the experimental paradigm occupies a hegemonic position. Thirty-one semi-structured interviews were conducted to explore biomedical scientists' receptiveness toward the social sciences in general and to qualitative research in particular. We found that these respondents exhibited …

Paradoxical Effects Of Interprofessional Briefings On Or Team Performance, Sarah Whyte, Lorelei Lingard, Sherry Espin, G. Baker, John Bohnen, Beverley Orser, Diane Doran, Richard Reznick, Glenn Regehr

Lorelei Lingard

Our recent research has found that structured preoperative team briefings can reduce communication failures, improve the knowledge and practice of operating room (OR) team members, and garner broad support from surgeons, nurses, and anesthesiologists. However, we have also encountered challenges and unexpected, negative effects. Using qualitative analysis of fieldnotes from 302 preoperative team briefings, we identified five paradoxical findings: team briefings could mask knowledge gaps, disrupt positive communication, reinforce professional divisions, create tension, and perpetuate a problematic culture. Fifteen percent of the briefings exhibited only these paradoxical effects without any apparent utility. We describe these paradoxical findings and analyze them …

Evaluation Of A Preoperative Checklist And Team Briefing Among Surgeons, Nurses, And Anesthesiologists To Reduce Failures In Communication, Lorelei Lingard, Glenn Regehr, Beverley Orser, Richard Reznick, G. Baker, Diane Doran, Sherry Espin, John Bohnen, Sarah Whyte

Lorelei Lingard

OBJECTIVE: To assess whether structured team briefings improve operating room communication.

DESIGN, SETTING, AND PARTICIPANTS: This 13-month prospective study used a preintervention/postintervention design. All staff and trainees in the division of general surgery at a Canadian academic tertiary care hospital were invited to participate. Participants included 11 general surgeons, 24 surgical trainees, 41 operating room nurses, 28 anesthesiologists, and 24 anesthesia trainees.

INTERVENTION: Surgeons, nurses, and anesthesiologists gathered before 302 patient procedures for a short team briefing structured by a checklist. Main Outcome Measure The primary outcome measure was the number of communication failures (late, inaccurate, unresolved, or exclusive communication) …

Interprofessional Information Work: Innovations In The Use Of The Chart On Internal Medicine Teams, Lorelei Lingard, Lesley Conn, Ann Russell, Scott Reeves, Karen-Lee Miller, Chris Kenaszchuk, Merrick Zwarenstein

Lorelei Lingard

An abundance of evidence suggests that communication in interprofessional healthcare teams is a complex endeavour. Even relatively simple communication processes involving information work - the gathering, storage, retrieval and discussion of patient information - may be fraught with pitfalls, and yet teams manage to conduct their daily information work, often with a high degree of effectiveness. In this article, we explore one commonplace dimension of information work - the use of patient charts to foster collaborative decision-making and care enactment - towards building an elaborated understanding of how teams innovate in the face of daily complexities in their information work …

Co-Management In Healthcare: Negotiating Professional Boundaries, Catherine Schryer, Olga Gladkova, Marlee Spafford, Lorelei Lingard

Lorelei Lingard

This article investigates discursive practices associated with the co-management of patients between healthcare providers. Specifically, we focus on two genres (38 referral letters and 37 consultant reports) written by optometrists and ophthalmologists — two groups who are experiencing interprofessional tension over their scopes of practice. In our analysis we foreground four kinds of modality associated with verbs — epistemic, deontic, phatic and subjective. We found that these healthcare providers shared in the epistemic resources used to hedge their sense of clinical certainty, and that ophthalmologists used deontic resources to control future action. However, we also noted that both professions used …